Page 63 - 2021 Advanced Ranger First Responder Handbook

Head Trauma
Open head injury results from application of force with penetration of the skull. The most common agents are missiles
and blunt instruments. Injuries caused by blunt instruments can cause open depressed skull fractures but are usually
of relatively low energy and cause only local injury to the brain. Nonetheless, these are serious wounds and have a high
potential for infection.
Closed head injury results from application of force to the head that does not involve penetration of the skull but may
involve scalp lacerations and facial fractures. The degree of injury to the brain is dependent on the energy transferred to
the brain as a result of the force applied to the head. Closed head injury most often results from falls and motor vehicle
accidents, even in an operational environment. Alteration of consciousness is the hallmark of brain injury, and may be
mild or severe, immediate or delayed, brief or permanent. Delayed deterioration of consciousness may occur as a result
of hematoma formation within the skull or worsening swelling of the brain. The mechanism for this impairment of con-
sciousness is increasing intracranial pressure, with subsequent impairment of brain perfusion (blood flow).

Assessment & Management
Generally, with head injuries the primary damage is done and there is little that can be done to correct that damage. The
primary goal of head injury management is to prevent secondary injuries associated with hypoxia, hypotension, anemia,
hyperthermia, and hypothermia. This equates to aggressive bleeding control and airway management. Avoid hypoxia
(any SpO2 < 92%), hypotension (any systolic blood pressure [SBP] < 110mmHg), and react to the signs of brain edema,
herniation, or seizures.
The hallmark of head injury is alteration of consciousness. This is best assessed using the AVPU Scale. Additionally,
the Military Acute Concussion Evaluation (MACE2) examination, particularly for mild TBI, should be performed. Pupillary
function is also important to assess, and this can be done with any light source. In bright sunlight conditions, closing the
eye for 30 seconds and observing while quickly opening demonstrates pupillary reactivity. Regular reassessment, as the
tactical situation permits, is critical as a neurologic status may vary significantly over time.
Inspection: Vital signs should be assessed in any patient with a head injury and patency of the airway confirmed. The
head should be inspected for signs of open injury or skull fracture. Open injury will be accompanied by a defect, and
basilar skull fracture may be associated with Battle’s sign (bruising behind the ear) or raccoon eyes (black eyes). Leakage
of cerebrospinal (clear) fluid from the ears or nose may also be present. The pupils should be inspected for equality and/
or reactivity. Unequal or nonreactive pupils in an unconscious patient are ominous signs.
Auscultation: Auscultation is generally not helpful in the evaluation of the head injury itself, but in a patient with impaired
consciousness, a full exam, including auscultation of the lungs, should be performed.
Palpation: Palpation of the head may reveal an underlying closed depressed skull fracture (an “ashtray” feel). The
cervical, thoracic, and lumbar spine should be palpated to assess for tenderness or deformity, possibly indicating an
associated spinal injury.
Management: Treatment involves securing the airway, maintaining SBP > 110, maintaining SpO 2 > 92%, elevating
the head of the litter to 30°, stabilizing the cervical spine if indicated, dressing any wound, and establishing an IV line.
Extended Care
Key aspects of field management of severe TBI are the prevention of hypoxia and hypotension. Ensure early establish-
ment of a definitive airway, aggressively treat respiratory compromise, administer oxygen if available (to maintain satura- H
tion SpO2 > 92%), and fluid resuscitate hypotension. DO NOT hyperventilate unless indicated for signs of herniation.
Controlled hyperventilation may be considered as a temporizing measure for evidence of increasing brain pressure and
herniation (deteriorating mental status, unequal pupils, posturing). Elevate the head of the litter to 30 degrees. Prevent
hypo/hyperthermia. Antibiotic prophylaxis for penetrating head trauma: ertapenem 1g IV/IO. Ensure casualty is evacu-
ated to a facility with a neurosurgeon available.

2021 ADVANCED RANGER FIRST RESPONDER HANDBOOK 53